Sheryl

HRT: Beyond possibly the initial determination that she is in menopause (if then...this is usually decided based on age and absence of menstruation), there are no blood tests involved. It is worth getting initial doctor consultation to ensure no contraindications to HRT (mainly through review of medical and family history). If there is not, then the HRT regimen is titrated to the lowest estrogen dose that produce symptomatic relief. The progesterone dose is pretty much fixed though there are alternatives in terms of duration e.g. continuous estrogen plus progesterone versus cyclic progesterone. Given the apparent lack of knowledge, this woman would be best advised to get doctor advice throughout. If she is Thai this can be done at no cost. Thai doctor will likely prescribe synthetic progestin and perhaps also synthetic estrogen, she can tell the doctor she only wants bioidentical and ask specifically about Oestrogel plus Utrogestan, Hyperthyroidism is a very serious condition and should be closely managed by an endocrinologist. Though your statement that thyroid levels were "low" a few years ago raises some doubt as to whether she is hyper or hypothyroid.

These hormones do nto require a prescription, and can be bought at a pharmacy, but availability varies by type. 1. Estrogen (estradiol) Easily found. Most common brand being Oestrogel, made by Besins (French pharma company) any large pharmacy will have it. It is an alcohol based gel, easy to apply and easy to titrate dosage. Personally I find that much less than the amount indicated on the applicator suffices, and one tube lasts me many months. 2. Progesterone: much harder to find, especially in the (preferred) transdermal form. You can get oral forms, brand names GynProgesterone and Utrogestan. the latter also made by French firm Besins and micronized for better absorption, I'm not sure about the first. Besins also makes a dermal progesterone gel called Progestogel bit it is offmarket in Thailand; it is what I use and I get it in Cambodia. Lacking that, Utrogestan is your best bet. 3. Vaginal estradiol/estriol (using systemic estrogen alone usually not enough for vaginal dryness). Several preparations, all rather expensive and can be hard to find: Femiest (Medisafe has this - but note dose is low, only 10 mcg so would likely need to use every other day after initial period of daily for 2 weeks) Ovestin (Very hard to find in Thailand but great preparation, I get it from Cambodia) Gynoflor (also contains lactobacillus)

Melatonin is not addictive. It is a natural body substance.

The amount of fluid one needs is tied to fluid losses which vary greatly depending on climate, activities, and body size. 2-3 liters will be about right in a temperate climate for a person of average size at rest. Anything that increases fluid losses, like sweating, diarrhea etc will considerably increase this. The best yardstick is urine: if it is clear or very light yellow in color, you are adequsteky hydrated. Darker, you need more fluid. Water content in food counts as fluid intake.

There is a prophylactic vaccine, that is the subject of the topic. It is actually the same vaccine as that given post exposure. It does not completely eliminate the need for vaccination after exposure, just reduces the number of doses to only 2 and eliminates the need for immune globulin. The same thing applies if an unvaccinated person receives the full course of post exposure vaccination aftrr a bite: on any subsequent bites they will need only 2 doses and no immune globulin. Rabies is just as awful a way to die as tetanus....and just as preventable.

If it is your own dog, then just vaccinate the dog. Where pre-expisure vaccination makes sense is if one works with animals (Vet, animal rescue) or must live/walk through areas with stray or wild animals.

If bedbugs there would be multiple bites and it would occur every night. For a single occurrence could be many things including spider. No way to be sure. Bickering/flaming posts have been removed.

To clariy, do you mean estrogen and progesterone for postmenopausal women or do you mean testosterone for men?

Should be available at all hospitals, public and private. But no guarantee. (Immune globulin).

Yes, it is done here.. This doctor is ecperienced in it https://www.bangkokhospital.com/en/bangkok/doctor/dr-romyen-jitmungngan

Bickering posts removed. note that Rabies Immune Globulin and Rabies Vaccine are different things. The vacvine can be givrn pre or post exposure and confers at least a few years of immunity. The immune globulin is short-acting and used (in addition to vaccine) only after exposure in unvaccinated people. Vaccine is readily available. The immune globulin can be harder to find.

Bickering and trolling posts have been removed

These things are all thoroughly proven. The virus was identified more than 120 years ago and there is no doubt whatsoever that it is the cause of rabies. The efficacy of the vaccine is also well established, and post-exposure vaccination, if started in a timely manner and continued for the full course, is almost 100% effective in preventing the disease. As with any vaccine, there are side effects. Mostly minor, but rarely a serious allergic reaction occurs (about 2.8 cases per million doses). It is not possible to be "treated for rabies" as no treatment exists once the disease has taken hold, and it is 100% fatal. Rabies in endemic in dogs and other animals in Thailand. Human cases are rare (less than a dozen per year) mainly because people are well aware of the need tio get vaccinated after a bite. Pre-exposure vaccine is recommended for people at high risk of bites, like veterinarians. For the general population, not usually recommended but can be done if desired. Living or travelling in areas with a lot of stray dogs would be a consideration. Important to note that there is still a need for vaccination after any bite even if vaccinated, but only 2 as opposed to a series of 5 injections, and no need for the immune globulin. The duration of protection from pre-exposure vaccination is unclear. High risk people (vets etc) are advised to get a booster every 3 years unless blood titers shows continued adequate protection. Besides hospitals, pre-exposure rabies vaccine can be obtained at clinics with vaccination services e.g. Bangkok: https://www.thaitravelclinic.com/cost.html https://wellmedbangkok.com/services/vaccinations-thailand/ https://www.medconsultasia.com/vaccinations/ Chiang Mai https://www.chiangmaiwellnessclinic.com/rabies https://www.healthcaremedicalclinic.com/ and hospitals

She can get care for free at the government hospital where she is registered under the universal coverage (AKA "30 baht" or "gold card" scheme.). All Thais know this so I don't think cost is the issue. If you prefer to pay for private care, Rutnin is best choice. But she would still have to agree to see a doctor...and you could end up paying quite a lot fof care she could have gotten for free. If her issue has to do with the long waits at government hospital, most have an after hours quasi private channel for consultation which is faster and has the added advantage of seeing senior doctor rather than doctors in training. Depending on the hospital maybe 250 - 500 baht more. Treatment meds etc still free.

The body excretes water via 4 organ systems: 1. Skin ( perspiration). 2. Respirartory system (exhaled breath always has some water vapour with it) 3. Gi tract - there is always water content in the stool. 4. Urinary systrm (Kidneys/bladder). The kidneys adjust the amount of water excreted according to the body's water balance. The skin adjusts perspiration according to the need for temperature regulation. The1 amount of water expelled via stool is mainly down to how rapidly contents pass through; at the start of the digestive process the contents are quite liquid and remain so until they reach the large intestine, whete water gets reabsorbed. In diarrhea contentd pass through to colon rapidly so stool is luwuid, leafing to water losses. In constipation dtool remains in thd colon unusually long, leading to more watet absorption and consequrntly hard stool. if your reason for thinking your kidneys are "underperforming" is reduced urination, this is often due to dehydration. Diarrhea and sweating will both lead to increased fluid loss and if fluid intake is not increased enough to offset it, the kidneys respond by conserving water (less urine volume, more concentrated urine). Serum creatnine is a good measure of kidney function. If it is in normal range your kidneys are working fine.

Make sure to have your cardiac function evaluated too if not done recently.

Still making no sense at all and not consistent with the doctor's written recommendation. No way are there THREE procedures envisioned. Per what he had written, he is proposing to do a ureteroscopy (URSL) on the left, presumably because it is suspected that there is a stone in the ureter; while lithotripsy could be tried instead, ureteroscopy is somewhat more successful when stones are lodged in the ureter. This is not the largest stone, you have same size on the right, but the issue is that it is lodged in the ureter and there are signs that it may be partially obstructing flow of urine from the left kidney. In the course of the URSL they can also remove any other, smaller, stones encountered on that side. Would not normally also do ESWL after that on the same side, the decision tree is ESWL vs URSL not both. And there is no mention in what he wrote of an ESWL on the left afterwards. Rather, he writes of elective ESWL later on the right side where there are apparently also at least 1 1.0 cm stone as well as some smaller ones. So 2 procedures, not 3 and only one essential. Do you have appointment with Prof. Ekkarin set up at SIPH? When you see him, ask: 1- does he concur that URSL is the best approach for the stone on the left? 2 - if so, could a bilateral URSL be done at same time (i.e. both sides) to also remove the stones on the right? (That might be the most efficient and least expensive approach. ) Understand that ESWL only breaks stones up into smaller stones, it does not dissolve them, so only worth doing for largish stones. Generally, stones 0.4 cm in size or less will easily pass on their own, and stones .4 - . 7 may also pass but with more difficulty. So the "20 stones" seen on your ultrasound are not really the issue (and indeed, many of them may already have since passed, I don't know the date of that US). It is the 1.0 cm stone that may be lodged in the left ureter, and a few stones sized .6 - 1.0 cm on the right, that are the issue.

Go to Siriraj and see the recommended doctor there. You need a complete treatment plan as well as investigations into underlying causes. The other link was just to give an idea of normal lithotripsy costs, but of course these prices assume not many stones. However I do not really see why the small stones (which is most of them) would need lithotripsy.

1.1 is actually not too large. Large enough to not pass on its own, but well within the size that lithotripsy might be able to break up. Sounds like many, perhaps even most, of the other stones are small enough to pass on your own (i.e. without needing to be btoken up by shock wave first), has conservative management been tried (e.g. hydration plus pain meds and an alpha blocker?) I do not see any indication on the estimate to suggest that there would need to be multiple admissions at that price, are you sure that is the plan? I cannot understand why it would be. Of course if the litho does not work, might have to then have surgery, that is always a possibility (not a certainty. A back up plan if the litho does not work). The larger issue is why so much stone formation. Do you maintain adequate hydration? Do you have an enlarged prostate causing urinary retention? Have you been evaluated for parathyroid issue? I continue to urge you to go to Bangkok and consult the recommended doctor for a comprehensive treatment plan. Bring a CD with the Xrays and ultrasound images on it.

P.S. Who told you that you have 20 kidney stones, that is pretty much unheard of. Or was that a typo? And how large is the largest stone?

would not be usual to need a CT for this. See my previous post.

Lithotripsy (shockwave therapy to break up stones) is not surgery. It is a non-invasive procedure. In fact sometimes done as a day procedure without overnight stay. While any large hospital will have CT, not all can do lithotripsy as this requires specialized equipment and expertise. Note that lithotripsy is not always successful, and skill of the doctor is paramount, not just in doing it but in deciding if it makes sense to do in the first place. Given how many stones you have, might or might not. I am not sure why CT needed, usually stones can be visualized by ultrasound (and sounds like they already have been)?? If they are going to have to operate to remove a stone that is too large for lithotripsy (a point you should perhaps get another opinion on before proceeding) via what I assume will be either Percutaneous Nephrolithotomy or Uteroscopy (laparoscopic approach through the urethra) I don't see why they would not remove the other stones at same time? In fact, if at least one stone is too large to remove otherwise, might make most sense to just go for a single operative procedure to remove all of them, the procedures just described can be done at same time on both kidneys....and might give the best chance of success. The whole thing as you describe it, does not seem to make sense. I think you need another opinion on treatment plan altogether. As for lithotripsy costs, 99k here https://phyathai2international.com/programs-and-promotions/Extracorporeal+Shock+Wave+Lithotripsy+(ESWL)/695/en However, the cost would likley be more for large number of stones. I strongly suggest you come to Bangkok (bringing CD of ultrasounds and all other medical records with you) and consult this senior doctor at Siriraj https://www.siphhospital.com/en/medical-services/doctor-biography?id=249 As there is a good chance you can be treated with a single procedure or surgery at a far lower cost. The treatment plan you describe seems odd to say the least. Most private hospitals in Thailand offer only private rooms, but with a range to choose from, which you select at time of admission or reservation. Unless you opt for one of the most costly VIP rooms, the room cost will be a very small factor in the total cost -- even though you may feel the room is unnecessarily nice or large.

Is the CT you require with or without contrast? What type of surgeries are these? Cost should not be sole consideration. Won't do you any good to have surgery done badly, or the wrong type of procedure -- both quite possible outcomes if surgeon not selected with care. Depending on what this is, you might be better advised to come to Bangkok. While other hospitals may cost less than BPH the diffetence is likely to be fairly small unless you to a government hospital. At these, wait fof CT is often very long hence my question about contrast. If no contrast media, CT at a stand alone imaging center eould be an option. I am frankly puzxled by refeence to 240k for "each Op". Rare for a surgery to cost that little at a private hospitsl these days, but again, I have no idea what exactly this is. BTW Pattaya Memirial, like most hospitals, does have CT. https://www.pattayamemorial.com/departments/radiology

Have you tried at all 3 places and found him not available at all? St Louis is ususlly jjust first come first serve. This sort of scheduling us typical of the best doctors. It refers only to their outpatient consultation hours, not their vompleye availability (for procedures etc). Not a good idea to select doctor based on convenience of scheduling, that usually gives poor results.

Above is a reasonable approach.